G.

Name: Manaysay, Alyson Jamilah E.

Age: 10

Sex: Female

Address: Bacnotan, La Union

Handedness: R

Civil Status: Single

Occupation: Student

Referring Unit: OPD

Rehab Dr.: Dr. Esperon

Date of Consultation: June 26, 2018

Date of IE: June 27, 2018

Dx: Levoscoliosis L1 – L4 apex L2

S:

HPI

c/c: pt. c/o of Intermittent dull aching pain on (B) lumbar area upon forward bending c PS 4-5/10

Pt. present condition began ~1 year PTIE (exact date unrecalled) when pt. began to feel
intermittent dull aching pain when forward bending or in a slouched position PS 3/10.

Pt. ignored the pain, and didn’t try any home remedies in order to alleviate the pain. Pt.
could no longer tolerate pain ~ 1 month ago (exact date unrecalled) and pt.’s family went to
Lorma Medical Center’s PT rehab for consultation. Pt. was diagnosed with levoscoliosis L1 – L4
apex @ L2 by Dr. Jay Esperon and advised to undergo PT rehab.

Past Medical and Surgical History

(+) GDD underwent PT rehab @ LMC 2010

(-) Heart Disease
(-) HTN
(-) DM
(-) OA
Medications
Pt. is currently not taking any medications.

Personal, Social and Living Environment History

- Sedentary lifestyle
- Pt. is a non-smoker
- Pt. is a non-alcoholic beverage drinker
- Pt. lives in a two-story house with room on the 2nd floor.
- ~14-15 steps going upstairs/downstairs
- 3 steps going from room to CR
- 20 steps going from room to sala

Family History
Condition/s Father Mother
Hypertension (-) (-)
DM (-) (-)
Heart Dse. (-) (-)
CA (-) (-)

O:
VS: before after
To 36.2o C 36.4o C
SPO2: 98% 99%
PR: 96 bpm 98 bpm

OI:
- Manner of Arrival: Amb s AD
- Physique: Mesomorph
- Mental Status: Alert/Coherent/Cooperative
- (+) Postural Deviation
- (+) Scoliosis
- (-) Gait Deviation
- (-) Deformities

Palpation:
- Normothermic on all exposed areas
- Normotonic on all exposed areas
- (+) taut band on (B) paralumbar and parathoracic areas
- (-) trigger points
- (-) crepitus
- (-) edema
- (-) swelling
- (-) nodules

Range of Motion

All major joints of (B) LE & UE are WNL actively and passively done pain-free with normal end-
feel except:
 Motions AROM PROM Normal Difference END FEEL
(R) SLR 0-60 0-82 0-90 30/8 Firm
(L) SLR 0-72 0-90 0-90 18/0 Firm
Trunk Flexion 0-70 0-80 0-80 10/0 Firm

Findings: LOM on (B) SLR and Trunk Flexion

Sig: LOM 2° to (m) guarding

Manual Muscle Testing

All major (m) groups of UE/LE and neck are assessed using break test and are grossly grade 5/5 except
the ff:

Muscle Group Grade

Trunk Flexors 4/5
Trunk Extensors 4/5
Trunk Rotators R: 4/5 L: 4/5
Findings: Decreased (m) strength on Trunk (m)s

Sig: decreased MMT grading d/t disuse

Special Tests

ST Procedure (+) sign Significance

Shober’s Test PT marks S2, 5 cm Difference between the Lumbar Spine Mobility
below, and 10 cm two measurements
above S2 of the pt.
PT measures the
distance between the 3
points, then asks pt. to
forward flex, then
measures distance.
Adam’s forward PT stands behind pt. Presence of rib hump Scoliosis
bending test with the pt.’s spine
visible. Pt. bends
forward at the waist
until the back comes in
the horizontal plane,
arms hanging and
knees extended. PT
looks for indicators of
scoliosis.
Postural Assessment

pt. position: standing

Landmark Anterior/Posterior Lateral

Head Midline Forward
Cervical Midline Increased cervical
lordosis
Shoulder (L) shoulder higher Rounded
Scapula (L) scapula higher (L) retracted scapula
Thoracic Towards (L) Increased kyphosis
Lumbar Towards (L) Normal

Findings: Flat back posture with forward head

Sig: 2o to scoliosis & postural habit

ADL’s: FIM LEVELS

Self-care No Helper
Feeding: 7 7 - Complete Independence
Grooming: 7 6 - Moderate Independence
Dressing: 6 5 - Minimal Independence
Upper Garment: 7
4 - Modified dependence, Min. Assist (75%)
Lower Garment: 6
3 - Modified dependence, Mod. Assist (50%)
Bathing: N/A 2 - Complete dependence, Max Assist (25%)
Toileting: 7 1 - Complete dependence, Total Assist (<25%)
Bed Mobility

Roll to right 7

Roll to left 7

Supine to sit 7

Sit to supine 7

Transfer
 Bed to chair 7

Sit to stand 7

w/c to toilet N/A

Ambulation 7

Assessment:

Pt. is a 10 y/o female diagnosed with levoscoliosis L1-L4 c apex @ L2. Pt. experiences pain
upon forward bending or prolonged slumped postures PS 4-5/10. Pt. has thoracic kyphosis and
forward headed posture 2o to postural habits. Pt. presents with LOM and decreased muscle
grade in the trunk d/t postural habituation. Pt. has modified independence in donning LE
garments d/t pain upon excessive forward flexion at the waist.

Rehab Potential:

Patient has good prognosis, pt. has sedentary lifestyle, but family is financially stable to
continue PT rehab and has no prior medical or family history which may complicate
rehabilitation. Pt. is cooperative during tx.

Problem List:

1. Pain on Thoracolumbar area

2. Difficulty in ADL’s as to donning LE garments.
3. LOM on Trunk Motions
4. Decreased muscle grade on trunk motions
5. Postural Deviation
6. (+) Taut band on para thoracolumbar area
LTG 6 sessions, 2-3x/week

1. Pt. pain will be eliminated on Thoracolumbar area.

2. Pt. will be able to perform all ADLs without signs of difficulty, pain or discomfort
3. To achieve (N) ROM on all trunk motions
4. Pt. will achieve (N) muscle grade on trunk motions
5. Pt. will achieve normal posture
6. Pt. taut band will be eliminated

STG 3 sessions, 2-3x/week

1. Pt. pain on Thoracolumbar area will be decreased from PS 4-5/10 -> PS 2/10
2. Pt. will be able to perform all ADLs s any signs of discomfort and difficulty
 3. To increase ROM on all trunk motions by 5o increments
4. Pt. will be educated as to PBM
5. Pt. taut band will be decreased on para thoracolumbar area.
Plan

PTMx

1. US x 1.5 w/cm2 x 5’ on (B) P-T-L area

2. HMP x 20’ on SA
3. GPS on (B) hams x 30sh x 3 reps x 1 set
4. AROME on (B) LE x 10 reps x 1 set, AP
5. Pelvic Briding x 7 sh x 10 reps x 1 set
6. Abdominal Isom x 7 sh x 10 reps x 1 sets
7. Klapp’s exercise towards (L) done in standing x 7 sh x 10 reps x 1 set